The most gratifying aspect for me has been the outpouring of emails from doctors and nurses who feel a growing divide between their front-line wisdom and a new corporate hospital climate. Transparency is their manifesto.

The many patients who have sent me their personal stories remind me that the problem has a tremendous emotional as well as financial cost.

For example, in response to my recent article for The Journal, Cynthia McLendon shared this story:

We spent Sunday night in the ER with my mother-in-law (not unusual). We have a laminated sheet that we bring with us that lists all of her doctors, her daily meds and time she takes them, her dialysis schedule, what she takes on dialysis days and non-dialysis days, location of her fistula, prior conditions, allergies and we can all recite her entire medical history. Despite all this, we still have conversations every time at the same hospital like this:
Dr. : She had a mitral valve replacement
Us: Aortic
Dr. It says mitral.
Us: We told you last time it was aortic. It was done at this hospital by Dr X 2 years ago. It’s in her record. We can have him call you.
Dr: Ok. We’re going to do a CT
Us: Don’t use contrast dye.
Dr. Why not?
Us: She’s allergic to it. It’s on that sheet, we just told you, it’s also in her record and we told you again a minute ago. Because 3 admissions ago you almost killed her with it and we are trying to save you a lawsuit.

In L&D [labor and delivery] today, looking at the board, I thought NO private hospital in town would take care of my patients. We are an inner city academic center, and we get the most complicated cases. I’m sure our numbers would look much worse than the Super Private Hospital down the road that doesn’t take Medicaid patients.

I remember one of those private physicians calling me one night to transfer a train wreck, [the patient] had been in their ICU for weeks and wasn’t getting better. I was stunned. I asked her why she couldn’t take care of this patient, she said “This is YOUR kind of patient.”

When I lived in Nashville I remember a physician friend telling me that if I wanted my gall bladder out go to one of the private hospitals, their food was better. But If I were truly sick, to go to Vanderbilt.

None of us walk on water, but for some of us, the water is just a lot deeper and more treacherous. So a grading system has to take that into account.

As a surgeon at a large referral hospital, Dr. Jones’ comments echo true to my world.

I, too, take care of sicker, more high-risk patients, which is why we need to use doctor-endorsed ways of measuring quality. Flawed rating systems that do not take this difference into account run the risk of steering patients the wrong way and punishing doctors like Dr. Jones for doing admirable work.

Doctors’ groups measuring quality, like the American College of Surgeons, have developed mathematical ways to appropriately adjust for differences in patient risk seen at one hospital versus another.

In addition, patient satisfaction survey questions asking: “Was your plan of care explained to your satisfaction?” also measure universal best practices. While there is no single best way to measure healthcare, there are many databases managed by doctors associations that measure hospital outcomes. The question we must now ask as a society is: Do patients have a right to know about the quality of their hospitals?

Transparency has the potential to change the focus of a marketplace. Currently, we have competition in healthcare, but the competition is at the wrong level. With increased transparency of performance and the realities of patient experience, hospitals will respond by allocating resources into quality and an improved experience.

As a medical student, I never heard of the problem of medical error or overtreatment discussed, let alone quantified. Later, the Institute of Medicine reported the estimate that those problems result in up to 98,000 deaths each year. Proud of my profession, I, along with my peers, disputed the figure.

But study after study by respected institutions have shown that the highly-cited 98,000 deaths figure vastly understated the problem.

We as a nation spend a lot of money on heart disease and cancer, but with preventable deaths, we are still debating if we even have a problem?

The problem of over-treatment and under-treatment also gets bigger the more we study it.

Physician specialists have been reporting in their own peer-reviewed literature and in our top journals that individual services (stents, PAP smears, follow-up radiology tests, certain prescribed medications, etc.) are not indicated up to 40% of the time.

We need to step back and take a global look at these studies in aggregate and put them in the context of what front-line doctors are telling us about the vitals signs of our healthcare system.

If we are going to finally get serious about addressing the large burden of waste in healthcare so that American businesses can thrive and healthcare can accommodate our projected aging population, the first step is to be open and honest about the task.

Comments (5 of 16)

Of course, you realize that CMS and the private insurers DO NOT REIMBURSE ERRORS and this provides a very hostile environment for patients (especially the elderly) when hospitals misuse "observation" and "unilateral DNRs" to cap their UNREIMBURSED costs.

We really need a mandate to physicians from CMS to SEEK informed consent for either palliative care OR curative care in order to prevent OVERTREATMENT for PROFIT and UNDERTREATMENT (that shortens life) for lack of reimbursement from CMA.

1:43 pm December 3, 2012

FlyRN13 wrote :

As a better than 35 year nurse I've seen things that wil curl your hair. Imagine a hospital suddenly deciding that since peanut oil was so cheap it was changing all of its cooking oil to peanut oil. It was horrific. Nurses that were allergic to peanuts could no longer stand to go to the hospital cafeteria because of the fumes. What about the patients that were allergic, not to mention that pediatric patients have been having increased allergies to this nut (legume actually). They not only didn't think it out, they didn't care. The bottom line was/is al they care about.

10:57 am December 1, 2012

Beth PT advocate/former PM wrote :

I believe physicians need to share solutions and be heard by congress before any implementation of new healthcare policies. Our focus should be on prevention and wellness of patients not on making sure all the providers have met all the patient measures. The lack of Medicare and healthcare reimbursement including the costs of implementing an electronic medical documentation has negatively impacted primary care. Patients/People should be the focus not profits. More and more physicians are not able to operate alone. In order to survive the increases in malpractice and overhead. Many physicians need to seek personal mental and physical wellness before they try to convert their patient populations. Bed side manners and the hippocratic oath should be the number one priority of PCP.

6:59 pm October 8, 2012

Barry L. Friedberg, M.D. wrote :

Of all the places in the hospital, the operating room is clearly the most frightening, especially because of scare pieces like 'Coma' & 'Awake, the movie.'

Anesthesia given without a brain monitor is a 99.9% guarantee of being over medicated to avoid anesthesia awareness.

The problem with routine over medication is that those of us over 50 are more sensitive to the bad side effects of over medication, most importantly the loss of mental faculties!

The only mental function test patients receive after anesthesia is 'able to move all four extremities on command, that I respectfully suggest is a very low level of mental function.

As a 35-year, board certified, practicing anesthesiologist, I wrote 'Getting Over Going Under' to help the general public deal with the same anesthesia fears I dealt with nearly five years ago when I had my hip replaced.

All book proceeds support the pubic education message of my non-profit Goldilocks Anesthesia Foundation:

"No surgery under anesthesia without a brain monitor."

2:17 pm September 28, 2012

CW wrote :

I would like to give you the nurses perspective. I have been a med/surg nurse, home health nurse and years of PI, CQI, RM, whatever the new buzz word is. Over the last 25 years, unfortunately i have seen many changes, some for the good and many for the not so good. My goal, as i'm sure most in health care agree is to give the best care to my pts with whatever system we have to work with. When you see them in their homes trying to decide if they can afford their heart pills or food, or they have NO-ONE to help them get to the dr visits, it puts everything in perspective. Is there an easy solution NO, but as we argue which insurance co or which acndidate has the best plan, remember it took us many years to get into this mess, and it will not be solved overnight. But in all the debate, PLEASE dont forget the pt and families involved, as many times they get pushed to the side and dont have a voice.